I hereby grant permission to
Cable Muse Network LLC (CMN) to use my name, likeness and/or voice, or the name, likeness and/or voice of my minor child for
all publicity purposes and in any media format. Media formats include, but are not limited to: newspapers, magazines, television,
radio, film, or on the Internet. CMN shall retain all rights to all materials submitted.

Name (print): ___________________________________________

Signature: ___________________________________________

Witness ___________________________________________

Email Address:________________________________________

Cell or Home Phone Number:_____________________________

Name or “nickname” to be used for a minor: ______________________

Age: ___

Location (City, State)_____________________

Date: ___/____/2009

Submission
Reference: name of your video submitted or YouTube location(s):

___________________
If a CD is mailed to below note "Mail"

Cable Muse
Network, LLC

P.O.
Box 33443

Phoenix,
AZ 85067-3443

(888)
805-8481

www.cablemuse.com

Cable Muse Network LLC employees and their families may submit entries
however are not eligible to win contest prizes.